Survey

THE FIELDS MARKED WITH AN * ARE COMPULSORY

PERSONAL DATA

DISORDERS AND MANIFESTATIONS DETECTED IN CO-PRESENCE OF MAIN DIAGNOSIS: *

EPILEPSY

PHOBIAS(SPECIFY)

AUTOSTIMULATION(SPECIFY)

AUTOAGGRESSION

AGGRESSION TOWARDS OTHERS

DESTRUCTION OF THE ENVIRONMENT

REPETITIVE MOTRICITY

OBSESSIVE RITUALS

TARGETED HYPERACTIVITY

NON-TARGETED HYPERACTIVITY

SOMATIZATION (E.G. GASTROINTESTINAL DISORDERS)

NUTRITIONAL DIFFICULTIES(SPECIFY)

REFERENCE ACCOMPANYING PERSON

NAME *

SURNAME *

DATE OF BIRTH (DD/MM/YYYY) *

PLACE OF BIRTH *

NATIONALITY *

ROLE (PARENT, EDUCATOR, ETC.) *

TELEPHONE *

EMAIL *

FUNCTIONING

1) MAIN MEANS OF COMMUNICATIVE EXPRESSION *

Gestuale(SPECIFY)

VISUAL (AUGMENTATIVE COMMUNICATION)

VERBAL

OTHER(SPECIFY)

2) HOW DO YOU JUDGE THE COMMUNICATION CHANNEL USED BY THE CHILD TO COMMUNICATE HIS/HER OWN NEEDS? *

HE/SHE IS NOT ABLE TO COMMUNICATE HIS/HER PRIMARY NEEDS (E.G. HUNGER, THIRST, NEED TO GO TO THE BATHROOM)
HE/SHE ONLY MANAGES TO COMMUNICATE PRIMARY NEEDS IN SPECIFIC SITUATIONS OR WITH SPECIFIC PEOPLE
HE/SHE MANAGES TO COMMUNICATE PRIMARY NEEDS REGARDLESS OF THE SITUATION OR PERSONS
HE/SHE IS ONLY ABLE TO COMMUNICATE PRIMARY NEEDS AND EXPLAIN THEIR ORIGIN IN SPECIFIC SITUATIONS OR WITH SPECIFIC PEOPLE
HE/SHE MANAGES TO COMMUNICATE PRIMARY NEEDS AND EXPLAIN THEIR ORIGIN REGARDLESS OF THE SITUATION OR PERSONS

SENSORIAL ASPECT

3) WHICH OF THE FOLLOWING STIMULATIONS IS ANNOYING?

MUSIC *

Yes
No
I DON'T KNOW

LOUD NOISES *

Yes
No
I DON'T KNOW

SUDDEN NOISES *

Yes
No
I DON'T KNOW

PERSISTENT NOISES *

Yes
No
I DON'T KNOW

BRIGHT COLOURS *

Yes
No
I DON'T KNOW

REFLECTING SURFACES *

Yes
No
I DON'T KNOW

SUNLIGHT *

Yes
No
I DON'T KNOW

COLOURED LIGHTS *

Yes
No
I DON'T KNOW

THE DARK *

Yes
No
I DON'T KNOW

VISUAL ELEMENTS (IMAGES/VIDEOS) *

Yes
No
I DON'T KNOW

VIBRATION *

Yes
No
I DON'T KNOW

HEAT *

Yes
No
I DON'T KNOW

COLD *

Yes
No
I DON'T KNOW

BEING ALONE IN CERTAIN PLACES *

Yes
No
I DON'T KNOW

LARGE ENVIRONMENTS OR OPEN SPACE *

Yes
No
I DON'T KNOW

LONG CORRIDORS *

Yes
No
I DON'T KNOW

CROWDED PLACES *

Yes
No
I DON'T KNOW

INTERACTION WITH OTHER PEOPLE *

Yes
No
I DON'T KNOW

PHYSICAL CONTACT WITH OTHER PEOPLE *

Yes
No
I DON'T KNOW

SLIDING DOORS *

Yes
No
I DON'T KNOW

BEHAVIOURAL ASPECT

IN CASE OF FRUSTRATION OR INTOLERANCE, WHAT IS THE MOST AGGRESSIVE BEHAVIOUR THAT COULD BE MANIFESTED?

AGGRESSION DIRECTED AGAINST OTHERS *

No

Yes

WITH WHAT INTENSITY WAS THE EPISODE MANIFESTED? *

HE/SHE MANIFESTS THE INTENTION TO GRAB
HE/SHE MANIFESTS THE INTENTION TO HIT
GRABS THE OTHER PERSON
HITS WITHOUT LEAVING MARKS
HITS AND LEAVES MARKS

HOW FREQUENT ARE THESE EPISODES? *

HARDLY EVER (LESS THAN ONCE A MONTH)
RARELY (1-2 TIMES A MONTH)
SOMETIMES (ONCE A WEEK)
OFTEN (2-3 TIMES A WEEK)
MOLTO SPESSO (PIÙ DI 3 VOLTE ALLA SETTIMANA)

HOW LONG DO THESE EPISODES USUALLY LAST? *

LESS THAN A MINUTE
FROM 1 TO 10 MINUTES
FROM 10 TO 30 MINUTES
FROM 30 TO 60 MINUTES
MORE THAN 60 MINUTES